Question

Thad Lutz is a 54 y.o. admitted for a deep vein thrombosis (DVT) of the left leg. Five days ago, he had surgery for a left ruptured Achilles tendon sustained during a local 10K race. He has never been hospitalized prior to his outpatient surgery. Post-operative instructions include no weight-bearing on the left leg for 4 weeks. He has crutches but admits instead to “hopping around at home holding onto things” on his right leg. He has an IV line via infusion pump for heparin therapy for aticoagulation. He still requires oral pain medication for post-operative pain compounded by the

pain of the DVT. He is on complete bedrest with allowed use of a bedside commode (BSC).

1. As part of the routine admission assessment, a Morse Fall Scale is completed. Explain the variables that pertain to Mr. Lutz for this admission.

2. After reviewing the Medicare “never events,” which ones could present a risk to Mr. Lutz during this hospitalization?

3. The nurse identifies a potential diagnosis of Risk for falls related to imbalanced gait with an outcome of no episodes of falls during hospitalization. The nurse discusses the diagnosis with Mr. Lutz, but he does not view falling as a hazard. He states, “I am young and in great shape and getting around on one leg works just fine for me.” How would you approach this perspective so that a collaborative plan of care can be implemented with this patient?

Despite agreement on measures to ensure his safety, Mr. Lutz continues to “ambulate” to the bathroom without assistance instead of using the BSC. He uses the infusion pump and its rolling stand for balance and tells the nursing assistant that he does not want to bother anyone when he can figure it all out on his own. The nursing assistant tells the nurse, “That man needs to be tied down before he hurts himself.”

4. With the knowledge that Mr. Lutz still needs pain medication every 4 to 6 hours, would any kind of restraint be appropriate in this situation? Explain your rationale.

5. Recognizing that pain medications can impair cognition, discuss the interventions that you can put in place to avoid the need for restraints for this patient.

6. It is decided to implement the use of a bed exit alarm for Mr. Lutz. How will this device help decrease the incidence of falls for this patient?

Answer 1

The Morse Fall Scale (MFS) is a rapid and simple method of assessing a patient’s likelihood of falling.A large majority of nurses (82.9%) rate the scale as “quick and easy to use,” and 54% estimated that it took less than 3 minutes to rate a patient. "The scale consists of six items reflecting risk factors of falling such as: (i) history of falling, (ii) secondary diagnosis, (iii) ambulatory aids, (iv) intravenous therapy, (v) type of gait and (vi) mental status", and it has been shown to have predictive validity and interrater reliability. The MFS is used widely in acute care settings, both in the hospital and long-term care inpatient settings.

He is not having history of falls

He has no secondary diagnosis

He is having crutches as ambulatory aid

He is having iv therapy for pain and also heparin given

Gait is abnormal and normal mental status

The patient is not at a high risk group as only above 50 points High risk will be there